Verbal DNR from a conscious patient?

[berkeman]

I was working a standby shift at a "Senior Games" track meet last weekend, and had a strange request from a patient (65y/o male). He was exhausted after running in the 400m race, and was tripoding near the scorer's table. One of the scorers called me over because of something the athlete had said, "If I pass out, I don't want mouth-to-mouth".

I evaluated him as he recovered, and in the end he was fine, and I just assumed he was kidding around with what he had said. But later I started thinking about DNRs, and how to handle the situation where a conscious and non-altered Pt states his desire not to be resuscitated, and then codes on you. Does his verbal DNR obligate you to withhold resuscitation, or does he need a valid DNR (certificate or medallion/bracelet here in Alameda County) before you can withhold? I know that if he has a valid DNR but requests resuscitation before he codes, then you can resuscitate (link below), but I don't know how it works when it's the other way around.

Thanks.

http://www.acphd.org/layouts/containers/ems-ofm/ofm_pdf/OPERATIONS/DEATH_IN_THE_FIELD_web.pdf

 

[hometownmedic5]

By the letter of the law in Massachusetts, you are only able to accept a properly executed CC/DNR or MOLST; or the order of a verified, present, and active health care proxy with the proper paperwork.

Tattoos, verbal wishes, or whatever else you can think of is technically invalid. If presented with any alternative forms of advanced directives, your best bet is to call medical control and punt it to them and here’s why. If you go into business for yourself and decide to honor a DNR tattoo for example, and the family sues for negligent homicide, you’re guilty. Open and shut, no trial necessary. You failed to follow the regulations, which are very simple and very clear, and you eschewed the option of medical control.

There may be states with different laws, but that’s how it plays out here. Don’t make up the rules for yourself.

 

[SomeGuy9005]

"If I pass out, I don't want mouth-to-mouth". I suspect they were just trying to be funny. However, the concept of DNRs and Advanced Directives are founded in the notion of informed consent. Nothing about the statement seems informed by any sound medical knowledge. What does he mean by "pass out?" What does he mean by "mouth to mouth?" In that situation if they then collapsed in cardiac arrest, I would run the call like any other, unless there was some other reliable information that he has a valid DNR/MOST/Advanced Directive.

DNR/MOST/Advanced Directive laws vary greatly from place to place. The laws in my area are different than many other places. Here I get to deal with the lovely grey zone where I can honour a DNR that isn't present, so long as it is reasonable to believe that the DNR exists. How's that for muddy waters? And in fact I have stopped a resuscitation based on a DNR that wasn't present (in consultation with our online Emergency Physician).

I have yet to deal with a verbal DNR request in the field. However if I had a patient that I believed to be of sound mind who was in a situation that they were likely to deteriorate into cardiac arrest before I arrived at the hospital, and who told me that they did not want CPR; I'd jump on the phone to a Doc. Discuss the situation, the patient's history, their request, and see what they think. It's a terrible situation to be in, but we have a responsibility to respect the patient's wishes, within the confines of local laws and regulations.

 

[Peak]

Rarely do patients keep a DNR/MOST/other advanced directive on them when they call 911 or present to the ED. Around here if there is a reasonable belief that the patient has an advanced directive and there are no extenuating circumstances (ex: the victim of a crime, the party reporting the advanced directive has ulterior motives, the patient is young without considerable disease process, et cetera) then we can honor the advanced directive even if it is not in hand. This does certainly vary from state to state, and I would reach out to your medical direction for clarification if there is any doubt. When in doubt I would work the patient.

 

[wanderingmedic]

Do the right thing. If a patient does not want resuscitation and they code, contact medical control and explain the situation. It is unethical to go against a patient’s right to refuse care.

Yes, I know this is complicated if a written DNR is not present. I have run on many patients who do not have DNR paperwork immediately available, or have DNR paperwork that is not filled out correctly. However, if the family or other bystanders gives me information I find reasonably reliable, I will most likely hold compressions and just call OLMC for orders. I have never had an OLMC Doc tell me to resuscitate someone whose family is refusing resuscitation on behalf of the patient, or who has incorrectly filled out DNR paperwork etc. If it reasonably appears that the patient did not want resuscitation and I communicate my findings to the OLMC doc, they have always just given me a time of death.

For me this happens a lot with diff breather’s that are in need of intubation. If they refuse the tube and are (in my judgment) capable of refusing care I will simply start CPAP and explain the situation of the OLMC doc and receiving hospital. The ER has always held intubation if I explain that the patient or family refused intubation on scene. Granted, you need to make sure that they actually understand what they are refusing…a conversation for another topic I suppose.

The bottom line is that we should be patient advocates. We do what is in the best interest of the patient as we understand. If the patient does not want aggressive measures, we should advocate for their wishes when they can no longer advocate for themselves.

 

[NPO]

This is a grey area. I've asked a similar question on this forum before...

https://emtlife.com/index.php?posts/635570

There are a number of problems:

1. He said no mouth to mouth. I mean, I don't want mouth to mouth eather. Did he mean no mouth to mouth, or did he mean no rescusitate at all, believing that saying mouth to mouth equates to rescusitation.
2. Does this patient actually have an established DNR that just cannot be produced? Can family corroborate its existence and his wishes?
3. Does the patient have a chronic illness that would make a DNR likely?
4. Is the patient fully informed of whatever disease process is the problem, his treatment options and ultimate prognosis?
5. When the patient made the verbal request, was he under duress or did he have any pathologies that would potentially make him less coherent or of sound mind?


Legally, it's a very grey area. I've talked to doctors and a lawyer about this.
Ultimately, do what's right for the patient.
In my career I've had 2 critically ill patients do just this, and present a verbal DNR request but we're unable to produce a hard copy. In both cases I deferred to on line medical direction, and in both cases they agreed to honor the request and manage airway and oxygenation with noninvasive BLS technique.

 

[akflightmedic]

If we accepted verbal DNRs, there would be a ton of dead teenagers for sure!

"Like OMG, just kill me already", followed with a heavy sigh and eye roll...